Pediatric neurologic emergencies

Evaluation of Neurosurgical Emergencies in the Pediatric Emergency Department: Clinical Warning Signs

BACKGROUND

We aimed to evaluate the patients who underwent neuroimaging with suspicion of neurosurgery pathology and identify the clinical warning signs for the early recognition of neurosurgical emergencies.

METHODS

Patients aged one month to 18 years who underwent neuroimaging with a preliminary diagnosis of intracranial pathology requiring emergency surgery and symptom duration less than one month were included in the study. Patients were divided into three groups according to their definitive diagnosis as neurosurgical emergencies, neurological emergencies, and nonurgents.

RESULTS

A total of 140 patients were included in the study (the median age was 8 [interquartile range IQR 3 to 13] years and 52.8% were male). Neurosurgery emergency group and neurological emergency group were significantly younger than the nonurgent group (P < 0.001). Vomiting, meningeal irritation findings, and papilledema (grade 2 and above) were more common in the neurosurgical emergency group (P 0.029, 0.023, and < 0.001, respectively). For neurosurgical emergencies, in the presence of papilledema (grade 2 and above) and focal neurological deficit, the specificity was 99.2%, positive predictive value (PPV) 83.3%, negative predictive value (NPV) 88.1%, and odds ratio (OR) 36.8 (P < 0.001, confidence interval [CI] 4.04 to 336.0); in the presence of altered consciousness and focal neurological deficit, the specificity was 97.5%, PPV 50%, NPV 86.6%, and OR 6.4 (P = 0.014, CI 1.20 to 34.4).

CONCLUSIONS

Younger age, presence of vomiting, signs of meningeal irritation, papilledema grade 2 and above, and altered consciousness are the crucial "warning signs" of a potential neurosurgical emergency.

Neurologic Emergencies at the Extremes of Age

The diagnosis and management of neurologic conditions are more complex at the extremes of age than in the average adult. In the pediatric population, neurologic emergencies are somewhat rare and some may require emergent consultation. In older adults, geriatric physiologic changes with increased comorbidities leads to atypical presentations and worsened outcomes. The unique considerations regarding emergency department presentation and management of stroke and altered mental status in both age groups is discussed, in addition to seizures and intracranial hemorrhage in pediatrics, and Parkinson's disease and meningitis in the geriatric population.

Effective Treatment of Traumatic Brain Injury in Rowett Nude Rats with Stromal Vascular Fraction Transplantation

Traumatic brain injury (TBI) affects 1.9 million Americans, including blast TBI that is the signature injury of the Iraq and Afghanistan wars. Our project investigated whether stromal vascular fraction (SVF) can assist in post-TBI recovery. We utilized strong acoustic waves (5.0 bar) to induce TBI in the cortex of adult Rowett Nude (RNU) rats. One hour post-TBI, harvested human SVF (500,000 cells suspended in 0.5 mL lactated Ringers) was incubated with Q-Tracker cell label and administered into tail veins of RNU rats. For comparison, we utilized rats that received SVF 72 h post-TBI, and a control group that received lactated Ringers solution. Rotarod and water maze assays were used to monitor motor coordination and spatial memories. Rats treated immediately after TBI showed no signs of motor skills and memory regression. SVF treatment 72 h post-TBI enabled the rats maintain their motor skills, while controls treated with lactated Ringers were 25% worse statistically in both assays. Histological analysis showed the presence of Q-dot labeled human cells near the infarct in both SVF treatment groups; however, labeled cells were twice as numerous in the one hour group. Our study suggests that immediate treatment with SVF would serve as potential therapeutic agents in TBI.

Mortality in Children With Severe Head Trauma: Predictive Factors and Proposal for a New Predictive Scale

BACKGROUND

Traumatic brain injury is a public health problem around the world, and recognition of systemic sources of secondary brain lesions is crucial to improve outcome.

OBJECTIVE

To identify the main predictors of mortality and to propose a grading scale to measure the risk of death.

METHODS

This retrospective study was based on medical records of children with severe traumatic brain injury who were hospitalized at a level I pediatric trauma center between January 2000 and December 2005. Multiple logistic regression analysis was done to identify independent factors related to mortality. A receiver-operating characteristics curve was performed to verify the accuracy of the multiple logistic regression, and associations that increased mortality were verified.

RESULTS

We identified 315 children with severe head injury. Median Glasgow Coma Scale score was 6, and median Pediatric Trauma Score was 4. Global mortality rate was 30%, and deaths occurred despite adequate medical management within the first 48 hours in 79% of the patients. Age < 2 years (P = .02), Glasgow Coma Scale ≤ 5 (P < 10), accidental hypothermia (P = .0002), hyperglycemia (P = .0003), and coagulation disorders (P = .02) were all independent factors predicting mortality. A prognostic scale ranging from 0 to 6 that included these independent factors was then calculated for each patient and resulted in mortality rates ranging from 1% with a score of 6 to 100% with a score of 0.

CONCLUSION

Independent and modifiable mortality predictors could be identified and used for a new grading scale correlated with the risk of mortality in pediatric traumatic brain injury.

Validation of Acoustic Wave Induced Traumatic Brain Injury in Rats

BACKGROUND

This study looked to validate the acoustic wave technology of the Storz-D-Actor that inflicted a consistent closed-head, traumatic brain injury (TBI) in rats. We studied a range of single pulse pressures administered to the rats and observed the resulting decline in motor skills and memory. Histology was observed to measure and confirm the injury insult.

METHODS

Four different acoustic wave pressures were studied using a single pulse: 0, 3.4, 4.2 and 5.0 bar (n = 10 rats per treatment group). The pulse was administered to the left frontal cortex. Rotarod tests were used to monitor the rats' motor skills while the water maze test was used to monitor memory deficits. The rats were then sacrificed ten days post-treatment for histological analysis of TBI infarct size.

RESULTS

The behavioral tests showed that acoustic wave technology administered an effective insult causing significant decreases in motor abilities and memory. Histology showed dose-dependent damage to the cortex infarct areas only.

CONCLUSIONS

This study illustrates that the Storz D-Actor effectively induces a repeatable TBI infarct, avoiding the invasive procedure of a craniotomy often used in TBI research.

Transcranial Doppler can predict intracranial hypertension in children with severe traumatic brain injuries

PURPOSE

The purpose of this study is to evaluate the accuracy of emergency Transcranial Doppler (TCD) to predict intracranial hypertension and abnormal cerebral perfusion pressure in children with severe traumatic brain injury (TBI).

PATIENTS AND METHODS

A descriptive and retrospective cross-sectional study was designed through data collected from medical records of children with severe TBI (Glasgow coma scale ≤ 8), admitted to a level I pediatric trauma center, between January 2000 and December 2005. Early TCD examination was performed upon admission, and TCD profiles were considered as altered using previously validated threshold values for diastolic velocity (<25 cm/s) and pulsatility index (>1.31) or when no-flow/backflow was detected. Invasive intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring were considered as the gold standard to measure intracranial hypertension (ICH). Statistical analyses compared TCD profiles to increased ICP (≥ 20 mmHg) and abnormal cerebral perfusion pressure (<50 mmHg) at admission.

RESULTS

Non-invasive TCD and ICP monitoring were performed in 117 severe head-injured children. Mean age was 7.6 ± 4.4 years, with a male prevalence (71%). Median initial Glasgow coma scale was 6. TCD had 94% of sensitivity to identify ICH at admission and a negative predict value of 95% to identify normal ICP at admission. Its sensitivity to predict abnormal cerebral perfusion pressure was 80%.

CONCLUSIONS

The high sensitivity of admission TCD to predict ICH and abnormal CPP after trauma demonstrates that TCD is an excellent first-line examination to determine those children who need urgent aggressive treatment and continuous invasive ICP monitoring.

Initial predictive factors of outcome in severe non-accidental head trauma in children

OBJECT

The aim of this study is to evaluate the outcome of young children hospitalized for non-accidental head trauma in our PICU, to evaluate PRISM II score in this sub-population of pediatric trauma and to identify factors that might influence the short-term outcome.

MATERIALS AND METHODS

Files of all children less than 2 years old with the diagnosis of non-accidental head trauma over a 10-years period were systematically reviewed. We collected data on demographic information, medical history, clinical status, and management in the PICU. Three severity scores were then calculated: PRISM II, Glasgow Coma Scale (GCS), and Pediatric Trauma Score (PTS). Prognosis value of qualitative variables was tested with a univariate procedure analysis (anemia, diabetes insipidus...). Then, quantitative variables were tested with univariate procedure too (age, weight, PRISM II, GCS, Platelet count, fibrin, prothrombin time (PT)...). Potential association between variables and death was tested using univariate procedure. Variables identified by univariate analysis were then analyzed with multivariate analysis through a forward-stepping logistic regression.

RESULTS

Thirty-six children were included. Mean age was 5.5 months (8 days-21.5 months). Mortality rate was 27.8%. At admission, PTS, PRISM II, GCS, PT, PTT, and diabetes insipidus were significantly altered or more frequent in non survivors. Cutoff value for PRISM II at which risk of mortality increased was 17.5 (sensitivity = 0.8; specificity = 0.88).

CONCLUSION

PRISM II is a reliable and easy performing tool for assessing the prognosis of non-accidental cranial traumatism in young children. GCS and PTS, scores even simpler than PRISM II, showed good accuracy regarding survival prediction.

Management of severely injured children in road accidents in France: impact of the acute care organization on the outcome

OBJECTIVE

To examine the impact of acute care management on outcome in children severely injured in road accidents.

DESIGN AND SETTING

Prospective follow-up study conducted in 12 French pediatric intensive care units over a 24-month period.

PATIENTS

Excluding those in refractory shock or in brain death at admission, a total of 125 children aged <17 years admitted to the pediatric intensive care unit with severe trauma (Injury Severity Score > or =16) were included.

RESULTS

Intracranial pressure (ICP) monitoring and admission into a trauma resuscitation room (TRR) were used as proxy markers for the center management aggressiveness. Centers which admitted to TRR and monitored ICP when indicated in >75% of cases were called aggressive centers. Children with an ICP monitoring indication admitted to a TRR and monitored, as well as those without an indication treated in a TRR, were judged appropriately managed. A poor outcome at pediatric intensive care unit discharge was defined as a difference between the baseline and discharge pediatric overall performance category above 3, or a hospital death. Children with traumatic brain injury appropriately managed in a less-aggressive center were more likely to have a poor outcome than those appropriately managed in an aggressive center (odds ratio 7.56, 95% confidence interval 1.5-38.4), after adjustment for severity, age, and type of road user.

CONCLUSIONS

The management in a more aggressive center for children admitted to TRR and monitored for ICP, when indicated, is associated with a better outcome. This could be explained by a more extensive experience in trauma management.

Proposed cross-disciplinary training in pediatric neurointensive care

Training and research in pediatric neurointensive care require unique approaches to childhood diseases that reflect differences in the immature brain's response to injury or disease compared with adults. Pediatric neurocritical care is a collaborative effort to provide consultative care among pediatric subspecialists, coordinated by neonatal and pediatric intensivists. Valuable perspectives for clinical care, training, and research can also be learned through collaboration with adult neurointensivists. Pediatric neurointensive care is thus an emerging subspecialty that optimally functions by applying a broad collaborative effort among colleagues across multiple medical specialties in pediatric and adult medicine. Innovations in clinical services, educational pathways, and research agendas need to be developed for children that can be modified for younger and older adults. This review also stresses cross-disciplinary research and training opportunities in pediatric neurointensive care beyond physician training. Nonmedical faculty from multiple academic disciplines should also serve as mentors to design appropriate curricula and research plans for the specific trainee in their respective fields and across specialties. The discipline of neurocritical care must consider a life-course approach for the patient requiring neurointensive care from neonatal through childhood and adult ages, with cross-fertilization from diverse academic disciplines and investigative points of view.

Multimodality comparison of neuroimaging in pediatric traumatic brain injury

Traumatic brain injury is a common cause of death and disability in children; early neuroimaging has assumed an increasingly important role in evaluating the extent and severity of injury. Several imaging methods were assessed in a study of 40 children with traumatic brain injury: computed tomography (CT), T(2)-weighted magnetic resonance imaging (MRI), fluid-attenuated inversion recovery (FLAIR) MRI, and susceptibility-weighted imaging (SWI) MRI to determine which were most valuable in predicting 6-12 month outcomes as classified by the Pediatric Cerebral Performance Category Scale score. Patients were subdivided into three groups: (1) normal, (2) mild disability, and (3) moderate/severe disability/persistent vegetative state. T(2), FLAIR, and SWI showed no significant difference in lesion volume between normal and mild outcome groups, but did indicate significant differences between normal and poor and between mild and poor outcome groups. Computed tomography revealed no significant differences in lesion volume between any groups. The findings suggest that T(2), FLAIR, and SWI MRI sequences provide a more accurate assessment of injury severity and detection of outcome-influencing lesions than does CT in pediatric traumatic brain injury patients. Although CT was inconsistent at lesion detection/outcome prediction, it remains an essential part of the acute traumatic brain injury work-up to assess the need for neurosurgic intervention.

Neurointensive care unit system for continuous electrophysiological monitoring with remote web-based review

There is a need in the neurological intensive care unit for a single integrated bedside monitor for continuously monitoring the function of the patient's central nervous system. In this paper, we demonstrate the feasibility of building such a system and operating it in the intensive care environment. We have developed a fully automated system that samples electrophysiological waveforms of various modalities according to a schedule of predefined intervals along with routinely monitored cardiac and respiratory parameters. The system provides stimulation and acquires responses without requiring supervision. The electrophysiological data include brainstem auditory and somatosensory evoked potentials and epochs of the electroencephalogram. The system applies peak detection and spectral analysis to extract salient parameters from the raw waveforms. The results are made available immediately in real time on the local network for local review and further analysis. A web-based interface makes review by a qualified neurologist possible anywhere within the hospital's secure intranet during and after monitoring. This system could potentially give an early warning of impending herniation, subclinical seizures, and brain or spinal cord ischemia. We demonstrate its application in a few diverse neurological intensive care cases and a case in the interventional neuroradiology suite.

[Anesthesia-resuscitation for intracranial expansive processes in children]

The most frequent space-occupying cerebral lesions in children are brain tumors, mostly posterior fossa tumors and haematoma resulting from arteriovenous malformation rupture. They result in intracranial hypertension, directly or by compression of the cerebrospinal fluid pathway resulting in hydrocephalus. Their localization and compressive effects are responsible for specific neurological deficits and general problems. Posterior fossa lesions carry a high risk of obstructive hydrocephalus, cranial nerves palsy and brain stem compression, pituitary and chiasmatic tumors a risk of blindness, pituitary deficiency and diabetes insipidus, and cortical tumors a risk of motor deficit and epilepsy. All these parameters must be analyzed before choosing anaesthetic protocols, and surgical techniques. In the presence of life-threatening intracranial hypertension, emergency anaesthetic induction, tracheal intubation and ventilation are life-saving. The specific treatment consists in either hydrocephalus derivation, initial medical treatment with osmotherapy, or rarely surgical removal. In other situations, surgical process requires a highly deep, stable anaesthesia with perfect control of cerebral haemodynamics. Surgical positioning is complex for these long lasting procedures and carries specific risks. The most common is venous air embolism in the sitting position that must be prevented by the use of specific measures. In the postoperative period, the risk of neurological and general complications commands close surveillance, fast track extubation must be adapted on an individual basis.